The challenge of engaging patients in order to excel

Professor Mike Chester examines the challenge of engaging patients in the quest for customer excellence

Patients want the ‘S' in NHS to truly stand for service. The problem is that, all too often, the ‘S' in NHS stands for ‘system' – and if you become preoccupied with that, patients often emerge dissatisfied with their experience.

It is several years now since the Wanless report demonstrated that without major cultural reform the NHS would become unaffordable, and free market principles loom large as a seductive solution to many of the problems of healthcare service provision.

The problem is that even with the massive investment needed to manage a free market's payment systems, too many of the most frail and vulnerable would lose out.

So how do you reform service provision without tipping the most vulnerable babies out with the bathwater?

Services are not created, they evolve and there is a growing recognition that patients should have an active role in that process.

Patients as customers

In 1996, when we founded the National Refractory Angina Centre, our practice of treating patients as customers in order to engage them fully in service development was practically regarded as heresy.

But successful businesses invest heavily in intelligence to understand their customers' needs – what irritates and what delights them – and develop a culture of continuously refining the service in line with customer intelligence.

By routinely monitoring and continuously responding to patient satisfaction with every aspect of our service, we have reached a point where a score of under 90% is regarded as seriously as a formal complaint.

An early lesson for us was that simply asking patients to describe their feelings about the NHS yields a fairly standard positive response because patients are reluctant to complain. I think this has a lot to do with the patients' reliance on emergency and life-saving services.

Ask a drowning man what he thinks of a stinking trawler, full of scowling fishermen, and he will find plenty of positive things to say – especially if he thinks the sharks are circling.

Doctors brought up to extol the doctor-patient relationship are easily fooled into thinking that the lack of complaints means that their patients are delighted with the service.

But there is a genuine and profound fear of confronting the system. Ask a patient who is justifiably dissatisfied why they do not complain and they will usually imply that they are frightened of getting a ‘black mark'.

Listening and explaining

We found that spending a couple of hours over a cup of tea, listening and explaining, immediately resolves long-standing misunderstandings, improves quality of life, reduces admissions and enables patients to choose not to undergo unnecessary cardiac procedures.

We have shown that such an approach can be delivered in the community by primary care teams. Using PBC, the cash released from the avoided waste easily pays for the ‘luxury' of delivering a service that delights both the patient and doctor.

Even if the carrot of delivering the sort of patient-centred service most of us envisaged when we started out in medical school were not enough, the June 2008 GMC consent guidelines represent a fairly hefty stick for unreconstructed paternalists who would like to continue to decide what is best for their patients.

Can we afford to give patients what they want? We can't afford not to.

Professor Chester is the current holder of the Sunday Times/Henley Management College Customer Experience Leadership Award and is a special adviser to the NAPC on customer experience. He is consultant cardiologist and director of the National Refractory Angina Centre at the Royal Liverpool and Broadgreen University Hospital Trust